Exploring Mpox severity among advanced HIV patients

In a recent study published in The Lancet, researchers assessed the incidence of mpox in individuals with advanced human immunodeficiency virus (HIV) infection.

Study: Mpox in people with advanced HIV infection: a global case series. Image Credit: Corona Borealis Studio/Shutterstock
Study: Mpox in people with advanced HIV infection: a global case series. Image Credit: Corona Borealis Studio/Shutterstock


In July 2022, the World Health Organization labeled the multi-country outbreak as an international public health emergency. HIV-positive individuals have been disproportionately impacted, accounting for almost 38% to 50% of mpox diagnoses. The majority of HIV-positive individuals described in the 2022 case series exhibited HIV viral suppression reporting median CD4 cell counts of over 500 cells per mm3 with comparable clinical presentations, time till mpox viral clearance, and outcomes to those of HIV-negative individuals. According to data from the USA and Nigeria, individuals with greater HIV-related immunosuppression had poorer clinical outcomes.

About the study

In the present study, researchers presented the clinical features and consequences of mpox in a group of HIV-positive individuals with low CD4 cell levels.

The team recruited clinicians via international research networks involving the Sexual Health and HIV All East Research (SHARE) Collaborative as well as the Network of the Skin Neglected Tropical Diseases and Sexually Transmitted Infections Unit. Researchers in areas with a high frequency of mpox diagnoses were contacted and asked to contribute to mpox cases detected between 11 May 2022 and 18 January 2023.

A confirmed mpox case was defined as a specimen collected from any anatomical site with polymerase chain reaction (PCR)-confirmed mpox infection. This series was limited to HIV-positive persons aged over 18 years with a CD4 cell count of fewer than 350 cells per mm3 or, in countries where a CD4 cell count was not available, an HIV infection clinically categorized as US Centers for Disease Control and Prevention (CDC) stage C. In accordance with the generally accepted 2010 consensus statement that defined late HIV presentation as a CD4 cell count of fewer than 350 cells per mm3 or an AIDS-defining disease, the team included HIV-positive individuals having CD4 cell counts of less than 350 cells per mm3. Additionally, CD4 cell counts Less than 100, 101 to 200, 201 to 300, and 301 to 350 CD4 cells per mm3 were categorized as low, moderate, and high, respectively.


The study results described 382 cases of mpox infection in HIV-positive individuals with CD4 cell counts below 350 cells per mm3 from 19 countries. Of a total of 277 people 382 were from America, followed by 99 from Europe and six from Africa. In terms of clinical manifestations, 243 of 382 patients reported fever while 364 experienced a skin rash, which was first vesiculopustular in 297 persons and subsequently ulcerative in 84 persons. The median number of skin lesions reported was 15, with the median time to a resolution being 23 days.

Among 36 persons who reported having 100 or more lesions and 43 persons with a time to resolution of at least 40 days displayed CD4 cell counts of less than 200 cells per mm3 with detectable HIV plasma viral levels. There were 235 cases of vaginal lesions, 203 cases of anal lesions, 144 cases of oral involvement, and 20 cases of ocular involvement. Dermatologic, respiratory, and secondary bacterial infections were the most prevalent organ problems. Approximately 94 out of 382 individuals suffered dermatological problems. The prevalent manifestation among the patients was several, large and rounded ulcers with necrotic centers and a fresh, elevated border, either adjacent to orogenital regions or in distant sites while verrucous appearance was uncommon.

Six out of the 35 patients reported pleural effusion including one patient having mpox-positive PCR while three of 35 patients had ground-glass changes, including one with mpox-positive PCR and two having suspected opportunistic infections. A total of 12 people reportedly had neurological involvement, one of which was encephalitis with frontal, orbital, and temporal edema observed on computerized tomography (CT) scan, along with mpox-positive PCR result, a herpes simplex virus (HSV)-1- and HSV-2- and varicella zoster virus-negative results.

All disease complications were more prevalent in persons with a CD4 cell count of fewer than 100 cells per mm3 than those with over 300 cells per mm3. Almost 107 out of 382 people were hospitalized, with seven surviving admission to critical care and 27 passing away. Furthermore, 25 of 27 deceased patients had severe necrotizing or hemorrhagic skin lesions; 24 had bloodstream or deep tissue bacterial infections; 23 had respiratory symptoms and respiratory failure; eight had neurological involvement; 21 had rectal involvement; and 18 had oropharyngeal involvement.

Overall, the study findings showed that severe mpox infection was observed with a death rate of 15% among persons with advanced HIV-related illness and CD4 cell counts below 200 cells per mm3. The researchers believe that In every mpox case, HIV testing and testing for other sexually transmitted infections and CD4 cell counts, should be assessed.

Journal reference:
Bhavana Kunkalikar

Written by

Bhavana Kunkalikar

Bhavana Kunkalikar is a medical writer based in Goa, India. Her academic background is in Pharmaceutical sciences and she holds a Bachelor's degree in Pharmacy. Her educational background allowed her to foster an interest in anatomical and physiological sciences. Her college project work based on ‘The manifestations and causes of sickle cell anemia’ formed the stepping stone to a life-long fascination with human pathophysiology.


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